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Then, basing on the evidences reported earlier, the diagnostic algorithm should be as follows (Figure 1): In case of typical findings from DIF (ie, granular IgA deposits at the dermal�Cepidermal junction or at the papillary tips) and of positive anti-tTG testing, the diagnosis of DH and, accordingly, of CD can be confirmed. Therefore, treatment and monitoring of DH should be managed (see text that follows). In case of typical DIF results, but with negative anti-tTG antibodies, HLA DQ2/DQ8 testing is suggested. If negative, DH can be excluded, but if positive, patients should be further investigated. In Tyrosine Kinase Inhibitor Library research buy particular, EMA and anti-DGP antibodies should be tested in order to exclude a previous false-negative result for anti-tTG antibodies. If EMA or anti-DGP antibodies are positive, DH can be confirmed. If negative, the guidelines for the diagnosis of CD should be followed,8,53,54 including the implementation of duodenal biopsy, in order to confirm the intestinal involvement prior to starting a gluten-free diet. In case of negative DIF and the presence of anti-tTG antibodies, HLA DQ2/DQ8 testing is suggested. If negative, DH can be excluded, but if positive, patients should be further investigated. First of all, a new skin biopsy of perilesional skin for DIF should be performed, in order to exclude false-negative results due to wrong sample collection in the previous skin biopsy. If the new DIF shows typical DH findings, the diagnosis VAV2 can be confirmed. If DIF result is again negative, according to the guidelines for the diagnosis of CD, a duodenal biopsy is suggested.8,53,54 Lonafarnib nmr In case of negative results both for DIF and for anti-tTG testing, DH can be excluded and the clinical and histopathological findings of the patients should be revised in order to achieve a different diagnosis. Figure 1 Diagnostic algorithm for patients with dermatitis herpetiformis. Treatment As previously stated, DH is considered the specific cutaneous manifestation of CD; therefore, a lifelong gluten-free diet is the first-choice treatment of the disease. However, in the first month after the diagnosis or in the inflammatory phases of the disease, in which a gluten-free diet alone would not be enough to control the symptoms, several drugs can be used for variable periods of time, including dapsone, sulfones or steroids. Gluten-free diet A strict gluten-free diet is the mainstay for treatment of the spectrum DH/CD. The level of gluten allowed is